Shared intent in third-party donation will underpin the success of new surrogacy laws.

The demands for surrogacy treatments continue to grow worldwide. However the legal guidance for non-commercial surrogacy treatments remains inadequate, and this commentary argues how the forthcoming guidance on surrogacy from the UK Law Commissions would benefit from a bold decision based on previous experience derived from similar developments in three other areas of assisted conception.

Factors predicting clinical outcomes from 494 vitrified oocyte donation cycles at a UK-regulated egg bank.

RESEARCH QUESTION: Do donor age, AMH, AFC, BMI and reproductive history predict response to ovarian stimulation? Do donor and recipient clinical markers and embryology parameters predict recipient pregnancy and live birth? DESIGN: Retrospective cohort study of 494 altruistic oocyte donors aged 18-35 years; 340 were matched to 559 recipients. Predictors of donor total oocyte yield and total mature oocyte yield were identified. Total and mature oocyte number were compared according to stratified donor AMH and age. Donor, recipient and embryology parameters predictive of recipient primary outcomes (clinical pregnancy and live birth) were identified. RESULTS: Donor age and AMH predicted total oocyte yield (P = 0.030 and P < 0.001)) and total mature oocyte yield (P = 0.011 and P < 0.001). Donors aged 30-35 years with AMH 15-29.9 pmol/l had lower total oocyte yield (P = 0.004) and mature oocyte yield (P < 0.001) than donors aged 18-24 years. Up to an AMH threshold of 39.9 pmol/l, increasing AMH levels predicted higher total oocyte yield (<15 pmol/l versus 15-29.9 pmol/l, P = 0.001; 15-29.9 pmol/l versus 30-39.9 pmol/l, P < 0.001; 30-39.9pmol/l versus ≥ 40 pmol/l, P = 1.0) and mature oocyte yield (<15 pmol/l versus 15-29.9 pmol/l, P = 0.005; 15-29.9 pmol/l versus 30-39.9 pmol/l, P = 0.006; 30-39.9 pmol/l versus ≥40 pmol/l, P = 1.0). In recipients, the rate of transferrable embryos per oocytes received, fertilized and number of embryo transfers needed to achieve the primary outcome were predictors of cumulative clinical pregnancy (P = 0.011, P = 0.017 and P < 0.001) and live birth (P = 0.008, P = 0.012 and P < 0.001) rates. Recipient BMI (P = 0.024) and previous miscarriages (P = 0.045) were predictors of cumulative live birth rate. Donor age 18-22 years was associated with a lower incidence of recipient clinical pregnancy (P = 0.004) and live birth (P = 0.001) after the first embryo transfer versus donor age 23-29 years. CONCLUSIONS: Donor age and AMH are independent predictors of oocyte yield. Raised recipient BMI and history of miscarriages reduce cumulative live birth rates, which may be increased by selecting donors aged 23-29 years, instead of younger donors.

Vitrification and the demise of fresh treatment cycles in ART.

The advent of vitrification has transformed the therapeutic landscape in assisted reproductive technology. Clear evidence for this is provided by the dramatic rise in the number of frozen embryo transfer (FET) cycles being carried out annually. In this review, we examine the reasons that underlie this trend and the current evidence that points to the place FET cycles will come to inhabit in the future. Safety issues have been central to the narrative around the clinical application of vitrification and, as the evidence base grows, the risk benefit balance will become clearer for different patient groups. These will include recipients of donor eggs, as in some centres the use of cryopreserved donor eggs now exceeds that of fresh oocytes. Efficient cryopreservation techniques have also affected international transport of gametes and embryos, increasing international access. The profound changes that vitrification has created promises to fulfil a prediction made by this journal's founding Editor, Bob Edwards, that embryo and cryopreservation would solve many of the challenges presented by assisted reproductive technology.

The UK´s anomalous 10-year limit on oocyte storage: time to change the law.

There has been a growing recognition in the UK that the statutory storage limit for frozen eggs, which currently stands at 10 years, requires a review. The UK regulator, the Human Fertilization and Embryology Authority (HFEA), has recognized the problem and the Equality and Human Rights Commission is also sympathetic with the demand to change the current legislation. There is also strong desire on the part of assisted reproductive technology (ART) professionals and patients to change the current guidelines. For many women, the available alternatives of transporting their eggs to an overseas destination or having them fertilized with donor sperm and then stored as embryos is objectionable.

Patient pressure: is the tide of cross-border reproductive care beginning to turn?

Two important explanations exist for cross-border reproductive care: restrictive legislation at home and limited access to affordable treatment. Both have recently been subject to patient pressure, favouring domestic and not cross-border services. The oppressive effect of regulation has been best illustrated in Italy, where legislation introduced as Law 40 in 2004 imposed restrictions on embryo freezing and embryo selection. After a decade of legal challenges by patients, the components of Law 40 have now been deemed unconstitutional in Italy. Similarly, a paucity of donor gametes in the UK has left many patients with few options but to seek donors and treatments overseas. Yet new techniques of donor recruitment and a revised allowance of compensation now means that some UK clinics can meet all requirements for donor gametes and patient matching from their own resources.

Egg-sharing, consent and exploitation: examining donors' and recipients' circumstances and retrospective reflections.

Egg-sharing schemes involve a woman sharing a portion of her eggs with another in exchange for free or reduced-cost fertility treatment and have been regulated in the UK since 1998. However, while being perceived as a unique anomaly (within the UK system) such schemes have caused considerable debate. Some critics have been concerned that the benefit-in-kind (i.e. fertility treatment) offered in exchange for donating eggs might compromise the consent of potential donors, particularly those who have no other means to access treatment, and lead to exploitation and the commodification of gametes. This article reports empirical findings that engage directly with these concerns. First, data on the demographic characteristics, circumstances and treatment outcomes of donors and recipients are presented, followed by data on egg sharers' own retrospective assessments of egg-sharing and their opinions regarding its ethics and regulation. This study shows that, contrary to some expectations, there are very few differences in the characteristics, experiences and opinions of egg-sharing donors and recipients, and also highlights the overwhelmingly positive assessment of egg-sharing by women who have taken part in such schemes.

Emotional and relational aspects of egg-sharing: egg-share donors' and recipients' feelings about each other, each others' treatment outcome and any resulting children.

BACKGROUND: This paper presents finding from a study of the emotional and relational aspects of egg-sharing, exploring egg-share donors' and recipients' thoughts and feelings about each other, about each other's treatment outcome and any resulting children, as well as their attitudes towards disclosure of donor origins and contact between donors and donor offspring in the future. It is the first study of this population since the removal of donor anonymity in 2005. METHODS: A paper or online questionnaire was completed anonymously by 48 donors and 38 recipients who took part in egg-sharing between 2007 and 2009. Data were obtained on a range of measures-including demographics, family circumstances, motivations and anxieties, feelings about egg-sharing, retrospective assessments and views on regulation-and analysed to facilitate cross-group and within-group comparisons of donors and recipients. RESULTS: This study found very few differences between donors and recipients, as well as between successful and unsuccessful egg-share participants. Donors and recipients expressed sentiments of goodwill towards one another, and displayed attitudes of openness regarding disclosure decisions and future contact among donors and donor-conceived offspring. While some donors and recipients wanted to know the outcome of their donor's/recipient's treatment, others preferred not to. CONCLUSIONS: Most significantly, concerns voiced regarding the potential psychological harm to donors, particularly those whose own treatment ends unsuccessfully, were not borne out by the data.

China's model of egg donation is a policy lesson for Britain.

In a move designed to increase the UK's supply of donor eggs, the Human Fertilisation and Embryology Authority has recently agreed to a fixed-sum compensation policy for donors "which better reflects their expenses" and inconvenience. Such a policy, however, which is reliant on non-patient donors for its success, is in contrast to what appears the system in China, where egg donors can only be recruited from those having IVF (i.e. patient donors) and on a conditional egg-sharing basis. Commitment to an egg-sharing policy in the UK would provide a more equitable system of egg donation than a compensation policy.

Uterine sperm-egg transfer: a cost-effective alternative to IVF in anovulatory women.

Anovulatory women can prove extremely challenging patients in the fertility clinic, particularly if they are unresponsive to standard protocols of clomiphene citrate. Katayama and colleagues now report (in this issue) an intriguing option, which yielded surprisingly high success rates in 16 selected young (age <36years) patients. Very low-dose progressive stimulation (35 IU gonadotrophins per day for 7days, followed by 75IU per day for about 5days if necessary), combined with the direct transfer of unfertilized eggs and prepared spermatozoa, resulted in a birth rate of 50%. The authors note that, at the time of oocyte retrieval, no spontaneous ovulation had occurred in any patient.